Disabling tinnitus and third nerve palsy following pontine hemorrhage: Application of ICF framework

Key Clinical Message Spontaneous intracerebral hemorrhage commonly affects the brainstem. This report describes a 31‐year‐old male with hypertension who developed a pontine hemorrhage. The neurological deficits included left‐third nerve palsy, right‐sided weakness, and disabling tinnitus. Tinnitus is linked to central auditory pathway disruption. Magnetic resonance imaging revealed the hemorrhagic lesion and additional micro‐hemorrhages. The International Classification of Functioning, Disability, and Health (ICF) enhances rehabilitation by characterizing multifaceted stroke disability. The ICF profile revealed impairments in body structures/functions, limitations in activities/participation, and positive/negative environmental factors. ICF‐based goal‐setting informed interventions, including tinnitus retraining and physical/occupational therapy. Comprehensive ICF assessment is crucial for optimized, patient‐centered post‐stroke rehabilitation as it determines the extent of impact on functional level of the patient irrespective of disease severity.

report describes a 31-year-old male with hypertension who developed a pontine hemorrhage.The neurological deficits included left-third nerve palsy, right-sided weakness, and disabling tinnitus.Tinnitus is linked to central auditory pathway disruption.Magnetic resonance imaging revealed the hemorrhagic lesion and additional micro-hemorrhages.The International Classification of Functioning, Disability, and Health (ICF) enhances rehabilitation by characterizing multifaceted stroke disability.The ICF profile revealed impairments in body structures/ functions, limitations in activities/participation, and positive/negative environmental factors.ICF-based goal-setting informed interventions, including tinnitus retraining and physical/occupational therapy.Comprehensive ICF assessment is crucial for optimized, patient-centered post-stroke rehabilitation as it determines the extent of impact on functional level of the patient irrespective of disease severity.

K E Y W O R D S
ICF framework, third nerve palsy, tinnitus and Communication Disorders estimates that 10% of US population is suffering from some form of Tinnitus.][9] The International Classification of Functioning, Disability, and Health (ICF) codifies the multifactorial impacts of health conditions like stroke. 10The ICF enhances rehabilitation by elucidating specific limitations in body structures/functions, activities, participation, and environmental interactions.ICF-based assessment informs goal setting and interventions to optimize functioning and societal participation.
This report presents an ICF profile of a patient with tinnitus and oculomotor palsy following pontine hemorrhage.MRI confirmed the hemorrhagic lesion.ICF components were examined to capture the breadth of disability.Tinnitus management and multidisciplinary therapies were tailored accordingly to promote recovery.

| CASE PRESENTATION
A 31-year-old male with untreated hypertension presented with right-sided involuntary movements followed by disorientation and impaired consciousness with a GCS scale of 12. Examination revealed left ptosis, anisocoria, right hemiparesis, and extensor plantar response.Brain MRI revealed a hemorrhage in the right pontine tegmentum with extension into the midbrain and medulla (Figure 1) and the differential diagnosis of Cavernoma bleeding was ruled out by a radiologist.
The neurological deficits indicated a left-third nerve palsy and proper corticospinal tract involvement.During the hospitalization, the patient developed constant highpitched ringing in both ears.Tinnitus onset coincided temporally with the hemorrhage, implicating vascular disruption of central auditory pathways as the likely cause.He also experienced a persistent headache attributed to irritation of pain-modulating brainstem nuclei by the hemorrhage.
An ICF profile was created to characterize the myriad sequelae (Table 1, Figure 2).Impaired body structures and functions include the oculomotor nerve, corticospinal tracts, and central auditory system.Activity limitations comprised impaired vision, communication, self-care, and mobility.Tinnitus hindered concentration and sleep.Environmental factors like social support and rehabilitation access were facilitators, while personal factors such as young age and hypertension control motivation enabled progress.
Specific management approaches were implemented based on the ICF profile.For tinnitus, the patient underwent tinnitus retraining therapy involving sound therapy and counseling.Vision rehabilitation and physical/occupational therapy also focused on facilitating activities and participation.The ICF profile will continue guiding multidisciplinary care during outpatient rehabilitation.
The patient was the biomedical diagnosis: 1. Acute cerebrovascular accident, hemorrhagic infarct in the right pons extending to the midbrain and bilateral medulla;  This patient's disabling tinnitus (b2400) and third nerve palsy (b2152) resulted from a hypertensive pontine hemorrhage.The ICF framework enhanced understanding of the myriad neurological impacts.The brainstem houses vital sensorimotor infrastructure, including cranial nerve nuclei (s11051), corticospinal/corticobulbar tracts, and auditory/oculomotor pathways. 2ccordingly, lesions cause deficits referable to involved structures.The Oculomotor nerve tract was segregated into segments such as nucleus, fascicles, sub-archnoid cistern, Cavernous sinus, and intra-orbital segments. 11Oculomotor nerve fascicles originate from midbrain subnuclei before coalescing to exit the interpeduncular cistern. 4Though all segments of the nerve cannot be fully ascertained to the etiology, the involvement of partial third nerve palsy is confirmed with ptosis and mydriasis but spared extraocular movements.Medial longitudinal fasciculus damage produced a horizontal gaze palsy.Corticospinal tract involvement caused contralateral hemiparesis.
Tinnitus was a significant source of disability not directly attributable to focal damage.Instead, it likely arose from vascular irritation of central auditory networks. 5imilar central mechanisms induce headaches through the stimulation of pontine pain modulators.A disequilibrium in the pontine energy metabolism is attributed to the migraine pathophysiology, 12 The headache satisfied the diagnostic criteria of C (localized in accordance with the site of hemorrhage) and D (unresolved) and was attributed to the non-traumatic intracerebral hemorrhage.Refractory tinnitus and headaches represent major complications impacting the quality of life after brainstem hemorrhages.
Applying the ICF framework enabled a granular, patient-centered characterization of health-related domains.Beyond documenting neurological impairments, the ICF profile revealed resultant limitations in diverse activities and variable environmental influences two times, directly after the stroke; this could help follow the progress, obtain a prognosis, and make decisions according to future interventions.This understanding guided interventions targeting specific participation goals.Ongoing use of the standardized ICF language facilitates clear multidisciplinary communication and goal-driven rehabilitation. 10inally, the MRI was instrumental in precisely localizing the hemorrhage to the right pontine tegmentum.The correlation between MRI and functional performance confirmed the neurological deficits while excluding competing etiologies.Neuroimaging improves diagnostic  accuracy and prognostication in ICH.However, optimal outcomes require complementing imaging with holistic frameworks like ICF that capture lived experiences.

| CONCLUSION
This case exemplifies multifaceted disability following pontine hemorrhage.The patient exhibited left-third nerve palsy and right hemiparesis from damage to the relevant midbrain and corticospinal tracts.Additionally, he developed centralized tinnitus and headaches due to vascular irritation of auditory and pain pathways.These complications added significant disability not explained by structural injury alone.MRI precisely localized the hemorrhage and elucidated the neurological manifestations.
A large-scale evaluation of the ICF framework (bfunctions, s-structures, d-activities and participations, and e-environmental factors) on stroke patients indicated that stroke assessment using ICF is compatible with other common clinical scales. 13The ICF framework can be further simplified to include dichotomous responses which can be further evaluated by rasch analysis. 14omprehensive application of the ICF framework codified impairments in body structures/functions, limitations in activities/participation, and the impacts of environmental/personal factors.This understanding informed interventions, including tinnitus retraining therapy and physical/occupational rehabilitation, to address discrete participation goals.Ongoing use of the ICF structure and terminology will optimize multidisciplinary care.Neuroimaging and holistic paradigms like ICF are essential for accurate diagnosis and patientcentered management following turning off brainstem hemorrhages.

T A B L E 1 4 =ringing in ears or tinnitus 1 AuD 1 MD
ICF functioning profile: b: Body function; s: Body structures; d: Activity and participation; e: Environmental factors; prof: health professional or other professional; 0 no impairment; 1 mild impairment; 2 moderate impairment; 3 severe impairment; complete impairment; G: Intervention Goal; P = performance of…; C = capacity in.In environmental factors: +4: Complete facilitator; +3: Substantial facilitator; +2: Moderate facilitator; +1: Mild facilitator; 0: No barrier/facilitator; 1: Mild barrier; 2: moderate barrier; 3: Severe barrier; 4: Complete barrier.MD: Doctor of Medicine; PT: Physical therapy OT: Occupational Therapy; AuD: Audiologist.Body structures: Anatomical parts of the body such as organs, limbs, and their components Activities and participation: Execution of a task or action by an individual and involvement in a life situation Make up the physical, social, and attitudinal environment in which people live and conduct their lives